EMPLOYMENT APPLICATION

An Equal Opportunity Employer

It is the policy of AIMS & CSI (hereafter referred to as the Company) to afford equal employment opportunity regardless of a person's age, race, religion, color, national origin, sex, marital status, qualifying disability, veteran status or other protected class.

INSTRUCTIONS
The careful completion of this application is an essential step in our consideration of you for employment. You must complete the entire application. Ask for an extra piece of paper if you need to clarify or complete any responses. Your application will become inactive after 60 days unless you inform the Company, in writing, and prior to the expiration of the 60-day period, that you want your application to remain active for an additional 60 days. Before you complete and sign this application, please ask any questions that you may have. If you need a reasonable accommodation in order to complete this application form, please notify the Company.

PERSONAL INFORMATION

IF REFERRED, BY WHOM?
DO YOU HAVE A CDL?
If so, what endorsements do you maintain?

POSITION FOR WHICH YOU ARE APPLYING

LOCATION THAT YOU APPLYING
POSITION TITLE
CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING, WITH OR WITHOUT A REASONABLE ACCOMMODATION?
 Yes  No
ARE YOU PRESENTLY EMPLOYED?
ARE YOU SUBJECT TO RECALL AT ANOTHER JOB?
HAVE YOU EVER APPLIED TO THIS COMPANY BEFORE?
WAGE EXPECTED?
ARE YOU RELATED TO OR KNOW ANYONE WHO CURRENTLY WORKS FOR THE COMPANY?

EDUCATION HISTORY

Name and Location
Course of Study
Years Completed
Graduate
Diploma or Degree
HIGH SCHOOL
COLLEGE
OTHER
OTHER FORMAL EDUCATION OR EXPERIENCE THAT YOU FEEL IS RELEVANT TO THE POSITION FOR WHICH YOU ARE APPLYING, INCLUDING MILITARY EXPERIENCE:

MISCELLANEOUS INFORMATION

ARE YOU AT LEAST 18 YEARS OLD?
 
DO YOU HAVE LEGAL AUTHORIZATION TO WORK IN THE U.S.?
 
HAVE YOU WORKED UNDER A DIFFERENT NAME?
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
(If you reside in Oregon, skip this question. You will be asked to disclose felony convictions later in the hiring process.)

ARE ANY FELONY CHARGES CURRENTLY PENDING AGAINST YOU?
(If you reside in Oregon, skip this question. You will be asked to disclose charges against you later in the hiring process.)
Background checks for all applicants are mandatory after a conditional offer of employment is made.

PROFESIONAL REFERENCES - FORMER MANAGERS OR SUPERVISORS

Provide Names
Address
Telephone Number

EMPLOYMENT HISTORY

List below past and present employment, starting with most recent. Do not skip any employers. If there are gaps in history, please explain.

 

NAME AND ADDRESS OF EMPLOYER
POSITION TITLE
SALARY
BEGINNING
ENDING
DESCRIPTION OF DUTIES
SUPERVISOR'S NAME(S)
DATES EMPLOYED
FROM
TO
REASON(S) FOR LEAVING
MAY WE CONTACT THIS EMPLOYER?
 
NAME AND ADDRESS OF EMPLOYER
POSITION TITLE
SALARY
BEGINNING
ENDING
DESCRIPTION OF DUTIES
SUPERVISOR'S NAME(S)
DATES EMPLOYED
FROM
TO
REASON(S) FOR LEAVING
MAY WE CONTACT THIS EMPLOYER?
 
NAME AND ADDRESS OF EMPLOYER
POSITION TITLE
SALARY
BEGINNING
ENDING
DESCRIPTION OF DUTIES
SUPERVISOR'S NAME(S)
DATES EMPLOYED
FROM
TO
REASON(S) FOR LEAVING
MAY WE CONTACT THIS EMPLOYER?
 
NAME AND ADDRESS OF EMPLOYER
POSITION TITLE
SALARY
BEGINNING
ENDING
DESCRIPTION OF DUTIES
SUPERVISOR'S NAME(S)
DATES EMPLOYED
FROM
TO
REASON(S) FOR LEAVING
MAY WE CONTACT THIS EMPLOYER?
 

VOLUNTARY CONFIDENTIAL SELF IDENTIFICATION

Please select one option in each category. If you do not want to self-identify, check the box indicating this. Your responses are for EEOC reporting compliance only and will not affect the results of your application.

 

Gender
Marital Status
Race

APPLICANT STATEMENT

PLEASE READ CAREFULLY BEFORE SIGNING

You Must Date and Sign This Applicant Statement to Be Considered For Employment

AFFIRMATION I affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I also agree that any false information, misrepresentations, or omissions may disqualify me from further consideration for employment and may result in termination of my employment if discovered at a later date.

AUTHORIZATION I authorize the Company to investigate all statements contained in this application, to contact my previous employers, to contact educational institutions I attended, and to discuss with them my employment/education history with them. I authorize my former employers and any educational institutions I have attended to disclose and discuss my employment/education history and records, including my disciplinary records, and waive any right to notice of such disclosure or discussion.

EXAMINATIONS Should I receive a conditional offer of employment, I agree to submit to any physical, medical and/or psychological examination. I further authorize any physician, counselor or other treater conducting such examinations to release to and discuss with the Company the results of such examinations.

ACCOMMODATIONS I also understand that if I have a protected disability that affects my ability to do the job I seek, I may ask the Company to attempt to make a reasonable accommodation for it. I must make my request in writing to the Controller as soon as possible, and under the Americans with Disabilities Act, such notice must be given no later than 182 days after the date I know or reasonably should know that accommodation is needed.

DRUG/ALCOHOL TESTS I give my consent for the Company, through an authorized testing service of its choice, to collect blood, urine or other samples from me and to conduct any other necessary medical tests to determine the presence of alcohol, drugs, or controlled substances. I authorize the testing service to release to and discuss with the Company the test results and other relevant medical information. If I am accepted for employment, I also consent to be tested in the above manner during my employment when, in the Company's judgment, such testing is appropriate. I acknowledge that remaining free of illegal drug use and complying with the Company's substance abuse policy is a condition of my employment.

AT-WILL EMPLOYMENT I understand that all employees of the Company are employed on an at-will basis. I understand that this means that my employment is for an indefinite period of time and may be terminated by either the Company or me at any time, with or without cause, and with or without prior notice, warning or discipline. No person other than the President of the Company has authority to offer employment for any specified period or to make any contract contrary to the foregoing. Moreover, no such agreement will be enforceable unless it is in writing, pertains specifically to me, and is signed by the President of the Company.

RELEASE I release my current and former employers, the educational institutions I have attended, the physicians/counselors/treaters who examine me, the drug/alcohol testing service, the Company and each of their staffs and employees from any and all liability associated with the disclosure and discussion of any information, records or other documents that pertain to me.

CRIMINAL/CREDIT HISTORY In addition, depending on the position for which I am applying, I understand that the Company may request a criminal and/or credit history pertaining to me. If such a check will be required, I understand that I will be provided with additional notices and information about that process and my rights.

WAIVER OF LIMITATIONS PERIODS In exchange for the Company considering my application for employment, and except as prohibited by law, I agree that I must file any and all claims and/or lawsuits arising out of or pertaining in any way to my application for employment, employment, or termination of employment within six (6) months of the event giving rise to the claim and/or lawsuit. I understand that applicable statutes of limitations may be longer than six (6) months. However, I agree to be bound by this shorter, six (6) month period of limitations and accordingly WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY.

 

I HAVE CAREFULLY READ THE FOREGOING APPLICANT STATEMENT. I UNDERSTAND EACH PARAGRAPH AND AGREE TO EACH PROVISION SET FORTH IN THE APPLICANT STATEMENT. By filling out the signature line and submitting this application online, I am agreeing to the terms of this application.

Applicant Signature:
Date:
 

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE WITH THE FCRA (FAIR CREDIT REPORTING ACT)

This authorization and consent for release of personal information acknowledges that (Hereafter referred to as “Company”) and/or its agent, C4 Operations LLC, may now, or at any time I am enrolled in, assigned to, volunteer with or am employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to: searches of educational institutions attended; state driving records; financial or credit institutions; employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorney-at-law or other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been involved); records from the U.S. Veteran’ Administration; criminal history information on file in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers’ compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to C4 Operations LLC, the following information and/or copies of documents from my military service record: DD214, service record, and any disciplinary records.

I understand that these searches can be used to determine eligibility under the Company policies. Therefore, I authorize the consent for full release of records (either orally or in writing) to the authorized representatives of the Company. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and received, upon written request, a disclosure of the background report. I also understand that I may request a copy of the report from C4 Operations LLC, by sending a written request to 1201 Edgewood Rd SW, Cedar Rapids IA 52404-2344, calling (888) 519-6283 or submitting an email request though our website www.C4Operations.com. After reading this document, I fully understand its contents and authorize the background verification.

Are you applying for employment in California, Minnesota or Oklahoma?
If so, do you want a copy of any Consumer Report prepared concerning you?

I understand that California law requires Company to give me a copy of any report requested within three (3) days of the date the information was obtained and that failure to do so will expose Company to liability (Section 1786.16).

Signed Date:
Applicant (Print Name):
Applicant Signature:
Parent/Legal Guardian Name if Applicant is a Minor
Parent/Guardian Signature if Applicant is a Minor

Background Screening Information

Basic Information

 

Motor Vehicle Records Check

Address History Please provide a complete address history for the last SEVEN-year period.

Degree Verification

Employer Verification

Please note, in order to verify a job candidate’s employment history, we will be contacting the employer you provide information for on this form. If you do not wish for your current employed to be contacted, please provide a previous employer instead.

Professional License Verification